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- Legislation/Regulation 1
- Newspaper/Magazine Article 3
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- Web Resource 17
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- Meeting/Conference 3
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- Second victims 1
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- Health Care Executives and Administrators 42
Health Care Providers
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Search results for "Agency for Healthcare Research and Quality (AHRQ)"
- Agency for Healthcare Research and Quality (AHRQ)
- Error Reporting
2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No.16-0006-EF.
Hospital-acquired conditions (HACs), some of which are never events, have been an important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading to significant efforts to prevent these conditions. This update to a prior report from AHRQ details and confirms the declining rates in HACs between 2010 and 2013. The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years (2011–2013) than if the HAC rate had remained at the 2010 level. Consequently, the report estimates a $12 billion savings in health care costs and 50,000 fewer hospital patient deaths. These improvements coincided with nationwide efforts to reduce adverse events, such as the Partnership for Patients initiative and Medicare payment reform. The remaining burden of HACs suggests continued investment in this patient safety problem is needed.
Tools/Toolkit > Government Resource
Hospital inpatients' experiences: percentage of parents who reported how often providers prevented mistakes and helped them to report concerns.
Rockville, MD: National Quality Measures Clearinghouse; December 2015.
Parents can help to recognize and report problems that occur when their children receive inpatient care. This quality measure has been developed to assist hospitals in tracking how often clinicians prevent mistakes while providing care for pediatric patients and whether they inform parents about ways to report concerns.
Journal Article > Study
Metzger J, Welebob E, Bates DW, Lipsitz S, Classen DC. Health Aff (Millwood). 2010;29:655-663.
Computerized provider order entry (CPOE) has provided significant safety benefits in research studies, especially when combined with clinical decision support to prevent common prescribing errors. However, CPOE's "real-world" performance has been mixed, with high-profile studies documenting a variety of unintended consequences. This AHRQ-funded study used simulated patient records to evaluate the ability of eight commercial CPOE modules to prevent medication errors. The overall results were disappointing, as CPOE failed to prevent many medication errors—including fully half of potentially fatal errors, which are considered never events. The individual CPOE products varied significantly in their ability to detect potential errors. Some hospitals did achieve superior performance, which the authors ascribe to greater experience with CPOE and implementation of more advanced decision support tools. Another recent article found that reminders within CPOE systems resulted in only small improvements in adherence to recommended care processes. Taken together, these studies imply that CPOE implementation may not result in large immediate effects on safety and quality in typical practice settings.
Bethesda, MD; Agency for Healthcare Research and Quality. February 25, 2009.
This interview introduces an AHRQ-funded PIPS toolkit to help small and rural hospitals implement medication safety initiatives.
Omaha, NE: Jones K, Skinner A, Cochran G, Knudson A, Beattie S, Mueller K; for University of Nebraska Medical Center and Nebraska Center for Rural Research; 2007.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2008.
This announcement describes the 19 projects funded by the Agency for Healthcare Research and Quality in 2006 that studies the potential of simulation to improve patient safety.
Rockville, MD: Agency for Healthcare Research and Quality; March 2007.
The Agency for Healthcare Research and Quality announces the 2007–2008 Patient Safety Improvement Corps (PSIC) program. States and organizations participating in the program will select staff members and its hospital partners to train in patient safety improvement. The applications period for this program cycle is now closed.
Meeting/Conference > Meeting/Conference Proceedings
Hammons T, Piland NF, Small SD, Hatlie MJ, Burstin HR. Englewood, CO: Medical Group Management Association Center for Research; 2001.
This summarizes a multidisciplinary conference (November 30 and December 1, 2000) dedicated to developing a research agenda in ambulatory patient safety. It reviews current knowledge about patient safety and contains information from presentations and discussions of conference participants. Eleven consensus recommendations are provided. The project was supported by grant number R13 HS10106 from the Agency for Healthcare Research and Quality (AHRQ).
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.
Rockville, MD: Agency for Healthcare Research and Quality; January 2019.
Hospital-acquired conditions (HACs) represent a significant source of preventable harm to patients. The Centers for Medicare and Medicaid Services financially penalizes hospitals with increased numbers of HACs through the Hospital-Acquired Condition Reduction Program. This policy of nonpayment has prompted hospitals to focus significant resources on preventing HACs. This AHRQ report found a reduction in HACs from 99 per 1000 acute care discharges to 86 per 1000 discharges between 2014 and 2017, representing a decrease in 910,000 HACs and savings of $7.7 billion. Declines in certain HACs such as adverse drug events and Clostridium difficile infections were noted to be more significant as compared to others. A past WebM&M commentary highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure ulcer while in the hospital.
Audiovisual > Audiovisual Presentation
Health Services Research and the Health Research and Educational Trust. March 2, 2017.
Communication-and-resolution programs emphasize transparency and respect in discussions with patients and families following an adverse event. This webinar highlighted AHRQ-funded research and programs that explored the impact of communication-and-resolution programs and other strategies that focus on improving patient safety and reducing liability. Researchers from a recent special issue devoted to this work were featured speakers.
National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer.
Rockville, MD: Agency for Healthcare Research and Quality; December 2016.
Medicare nonpayment and reporting requirements have stimulated health care organizations to focus on reducing hospital-acquired conditions (HACs) such as health care–associated infections and never events. The Agency for Healthcare Research and Quality regularly tracks HAC rates, including rates of adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, falls, obstetric adverse events, pressure ulcers, surgical site infections, ventilator-associated pneumonias, and postoperative venous thromboembolisms. According to data from the AHRQ National Scorecard, HACs have decreased by 21% between 2010 and 2015. This represents a total of 3.1 million fewer HACs contracted by hospitalized patients over 5 years, saving an estimated 125,000 lives and $28 billion. These findings represent substantial progress and support the success of incentives designed to eliminate HACs as a source of patient harm.
Rosen AK, Chen Q. National Quality Measures Clearinghouse: Expert Commentaries; June 13, 2016.
The current measures designed to enable transparency and accountability are falling short of helping to reach those goals. This article discusses weaknesses in the existing metrics used to track patient safety improvement. Factors contributing to the problem include the myriad of measure sets, reliance on retrospective data collection and analysis, and gaps due to inconsistent methods of engaging patients and families in reporting safety-related events.
Legislation/Regulation > Government Resource
Patient Safety and Quality Improvement Act of 2005—HHS guidance regarding patient safety work product and providers' external obligations.
Agency for Healthcare Research and Quality. Fed Regist. 2016;81;32655-32660.
Patient Safety Organizations (PSOs) were formed with provisions to protect voluntarily submitted incident data to enhance transparency and learning from medical error. Despite those expectations, PSOs still have obligations to report certain situations to external organizations. This guidance aims to clarify what and when external reporting should take place for PSOs to remain in compliance with federal requirements while appropriately protecting incident data.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; May 2016.
Traditionally, health systems have disclosed adverse events to patients only through a lengthy process that involves providing limited information to patients and families, avoiding admissions of fault, and emphasizing protection of the clinicians involved. This approach may harm safety culture and has been criticized as not being patient-centered. Some pioneering institutions, such as the University of Michigan Health System, began implementing an alternative approach known as "communication and resolution," which emphasizes early disclosure of adverse events and proactive attempts to reach an amicable solution. Early adopters of this method have achieved notable results, including a decline in malpractice lawsuits. The CANDOR toolkit, developed by AHRQ as part of the Medical Liability Reform and Patient Safety Initiative, provides tools for health care organizations to implement a communication-and-resolution program. The toolkit includes videos, slides, and teaching materials, and it has been tested in 14 hospitals in several different states. A PSNet interview with the chief risk officer of the University of Michigan Health System discusses the organization's pioneering efforts to implement a communication-and-response system.
Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events. Final Report.
Schneider EC, Ridgely MS, Quigley DD, et al. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-0027-EF.
Patient safety hotlines are a strategy to improve reporting and collecting of comments from patients, clinicians, and staff to notify hospitals about problems in care processes. This report describes the development of one such program, the Health Care Safety Hotline. Drawing from design and testing of the hotline, the authors conclude that more research is needed to understand why patients were more likely to access reports than contribute to them and how to simplify goals for the tool to enhance its usefulness.
McNamara P, Shaller D, De La Mare J, Ivers N. Rockville, MD: Agency for Healthcare Research and Quality; March 2016. AHRQ Publication No. 16-0017-EF.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
Full disclosure programs have shown to be effective mechanisms for early resolution of adverse events. This article reveals one early adopter's experience with full disclosure and provides insights from the architects of the program to guide others in implementing similar strategies and spread success associated with the approach.
Journal Article > Study
Implementing hospital-based communication-and-resolution programs: lessons learned in New York City.
Mello MM, Senecal SK, Kuznetsov Y, Cohn JS. Health Aff (Millwood). 2014;33:30-38.
This study reports on an AHRQ-funded effort to establish communication-and-resolution protocols for general surgery in five New York City hospitals. The participating hospitals improved their incident disclosure but also encountered many critical obstacles to full implementation.
Journal Article > Review
Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Ann Intern Med. 2013;158(5 Pt 2):390-396.
Considered a never event for hospitalized patients, falls that result in serious injury remain relatively common despite increased attention to the issue. This systematic review identified approaches used to successfully implement fall prevention programs and found high-quality evidence that multicomponent interventions—including patient education, discontinuation of harmful medications, and wristband alerts—can significantly reduce inpatient fall rates. Although concerns have been raised that fall prevention programs could have unintended consequences, this review found that potential harms (such as increased use of sedating medications) had not been systematically evaluated. This review was conducted as part of the AHRQ Making Health Care Safer II report, and on the strength of this evidence, fall prevention strategies are considered one of the top ten patient safety strategies ready for implementation now. An institutional approach to fall prevention is discussed in an AHRQ WebM&M perspective.
Journal Article > Review
Sullivan N, Schoelles KM. Ann Intern Med. 2013;158(5 Pt 2):410-416.
As the patient safety evidence base matures, the focus is shifting from effectiveness (identifying which strategies can prevent errors) to implementation (ensuring that all patients receive effective strategies). Pressure ulcers are considered a never event, but their incidence has been increasing despite effective preventive strategies. This systematic review identifies several promising methods of implementing multicomponent interventions to prevent pressure ulcers and emphasizes the importance of leadership, simplification and standardization of safety strategies, and regular audit and feedback of pressure ulcer rates in ensuring intervention success. This study was funded by the Agency for Healthcare Research and Quality as part of the Making Health Care Safer II report and was published as part of a special patient safety supplement in the Annals of Internal Medicine.